Local anesthesia on the maxilla Local anesthesia Trigeminal nerve

Local anesthesia has two main components technical aspect and

a communicative aspect.
3 sensory nuclei + 1 motor nucleus

Dr. Ilana Gor

Department of Dental Surgery

Institute of Dentistry V1 – V2 – V3 –
Sechenov University OPHTHALMIC MAXILLARY MANDIBULAR
NERVE NERVE NERVE
Moscow, Russia
Sensory Sensory Sensory/Motor
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Maxillary nerve The posterior superior alveolar nerve

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Middle meningeal nerve
Sensory fibers to orbit
Nasal branshes
Nasopalatine nerve
Greater palatine nerve
Lesser palatine nerve
Pharyngeal branch
Zygomatic nerve (zygomaticofacial,
zygomaticotemporal)
Posterior superior alveolar nerve
Infraorbital nerve
Middle superior alveolar
Anterior superior
Inferior palpebral https://live.staticflickr.com/3891/14579307248_eb7c21a77f_b.jpg

Lateral nasal
Superior labial
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Nasopalatine nerve (Incisive nerve) Palatine nerves The infraorbital nerve
1. Greater palatine nerve
1. Anterior superior alveolar nerve
2. Lesser palatine nerve
2. Middle superior alveolar nerve
3. Inferior palpebral nerve
4. Nasal nerve
5. Superior labial nerve

Dental plexus The maxilla Local anesthesia techniques on the maxilla

The maxilla consists of the body and its four projections: Local infiltration – is an injection of local anesthetic near to the
1. frontal process small terminal nerve endings after which anesthetized a small,
isolated area involving the tissues in and around one or two teeth
2. zygomatic process
Nerve block – Local anesthetic is deposited near to the larger
3. palatine process nerve branches as infraorbital nerve or nasopalatine nerve
4. alveolar process Trunk nerve block - Local anesthetic is deposited close to the
main nerve trunk as maxillary nerve (V2) or mandibular nerve (V3)

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Terms Local anesthesia techniques on the maxilla Submucosal
• Needle insertion point Injection site where bevel of needle is The following techniques are available: Indications
covered with tissue. Infiltration • Pulpal anesthesia
• Direction of the needle insertion • Submucosal • Soft-tissue anesthesia
• Depth of needle penetration Describes needle depth covered • Subperiosteal (recommended for limited treatment protocols) Contraindications
in tissue when target area is reached. • Inflammation in the area of injection.
• Periodontal ligament injection (PDL, intraligamentary)
• Deposit location Target area where local anesthetic will be • Thick cortical bone in the area of the injection (e.g. around the
deposited. • Intraseptal injection permanent mandibular first molar)
• Nerves anesthetized – terminal nerve ending at the site of • Intrapulpal injection Deposit location
injection and at the apex of the tooth • Intraosseous injection (IO) • Apex of the selected tooth
• Areas anesthetized – bone, soft tissue, and apical and pulpal Needle insertion point
tissues in the area of injection • Height of the mucobuccal fold or palatal surface
Volume of the injected solution
• 0.3-0.5 ml

Submucosal Submucosal Submucosal

1. Assume the correct position depending on area anesthetized 7. Deposit several drops of anesthetic
2. Ask the patient to open mouth 8. Advance the needle until its bevel is at the apical region of the
tooth
3. Retract the patient’s upper lip
9. Make Aspiration test
4. Use the topical anesthesia and wait for 1minite.
10. Deposit approximately 0.5 mL of solution
5. Hold the syringe and orient needle bevel toward the bone at an
angle 40-45 degrees 11. Carefully withdraw the syringe
6. Insert the needle into the mucobuccal fold over the target tooth 12. Immediately recap the needle
(for infiltration on vestibular site) or in the angle which formed by 13. Wait approximately 3–5 minutes until anesthesia takes effect
two process alveolar and palatal over the target tooth (for before starting treatment.
infiltration on palatal side)
Why the anesthesia could be Inadequate ? Subperiosteal Subperiosteal injection
• Crossover-innervation The subperiosteal injection can be accomplished on any tooth of • Step 1-7 similar to submucosal anesthesia
either dental arch by depositing the anesthetic solution under to
• Solution is deposited inferior to the apex of the tooth the periosteum overlying the apex of the tooth.. 8. The needle is advanced towards the apex of the tooth,
• Dense bone covers the apices beneath the periosteum.
Indications
• Area of infection 9. Make Aspiration test
• Pulpal anesthesia
• Pain during injection 10. Slowly deposit about 0.5-0.7 mL of local anesthetic solution.
• Soft-tissue anesthesia The periosteum will force the solution through the cortical plate
Contraindications and into the cancellous bone.
• Inflammation in the area of injection. • Step 11-13 similar to submucosal anesthesia
Deposit location
• Apex of the selected tooth
Needle insertion point
• Height of the mucobuccal fold or palatal surface
Volume of the injected solution
• 0.5-0.7 ml

Subperiosteal injection Subperiosteal injection Periodontal ligament injection (PDL,

Advantages
intraligamentary)
• There is no great trauma. Indications
• Pulpal and soft-tissue anesthesia in a localized area (one tooth)
• It is more appropriate, more specific and definite in region.
• If required anesthesia without extensive soft-tissue anesthesia
• It is safe and much more effective than submucosal injection.
• Situations in which regional block anesthesia is contraindicated
• The onset of action is rapid.
• As an adjunctive technique after nerve block
Disadvantages Contraindications
• Painfull • Infection or inflammation
• Anesthetized only one-two teeth Deposit location
• Depth of gingival sulcus
Needle insertion point
• Along the long axis of the tooth to be treated
Volume of the injected solution
• 0.2-0.6 ml
PDL Injection PDL Injection PDL Injection
The PDL anesthetic injection technique, also referred to as the Advantages
“intraligamentary injection technique,” can induce local • Prevents anesthesia of the soft tissues
anesthesia in either maxillary or mandibular teeth. Although
occasionally it is used as the primary anesthetic technique (when • It is required minimum dose of local anesthetic (0.2 ml per
a single tooth requires anesthesia for a short duration), dentists root)
most often use the PDL technique when mandibular nerve blocks • An alternative to partially successful regional nerve block
are unsuccessful anesthesia
• Rapid onset
• Step 1-4 similar to submucosal anesthesia • Less traumatic than conventional block injections
• Keep the needle along the long axis of the root to be Disadvantages
anesthetized
• Proper needle placement is difficult to achieve in some
• With the bevel of needle on the root, advance the needle areas.
apically until resistance is met
• A special syringe may be necessary.
• Deposit 0.2 ml of local anesthetic solution in a minimum of 20
• Excessive pressure can produce local tissue damage
sec
• Post injection discomfort may persist for several days
• If tooth is multi-rooted, remove the needle and repeat the
procedure on the other roots

Intraseptal injection Intraseptal injection Intraseptal injection

Indications Advantages Step 1-4 similar to submucosal anesthesia
• Pulpal and soft-tissue anesthesia in a localized area (one tooth) • It is required minimum dose of local anesthetic • Slowly inject a few drops of papilla adjacent to the tooth
• If required anesthesia without extensive soft-tissue anesthesia • An alternative to partially successful regional nerve block • Frontal plane: 45 degrees anesthetic in a minimum of to the long
• Situations in which regional block anesthesia is contraindicated anesthesia axis of the tooth, Sagital plane: at right angle to the soft tissue.
• As an adjunctive technique after nerve block • Rapid onset Bevel facing the apex of the tooth
Contraindications • Less traumatic than conventional block injections • Step 11-13 similar to submucosal anesthesia
• Infection or inflammation Disadvantages
Deposit location
• Multiple tissue punctures may be necessary
• Interdental septum
• Short duration of pulpal anesthesia;
Needle insertion point
• Limited area of soft-tissue anesthesia
• Apical to the apex of the papillary triangle.
Volume of the injected solution
• 0.2-0.4ml
 Intrapulpal injection Intrapulpal injection
Indications • Deposition of local anesthetic directly into the pulp chamber of a
• Failure of others anesthesiological techniques tooth
Contraindications • The intrapulpal injection may be used on any tooth when
difficulty in providing profound anesthesia
• None
Deposit location
• Step 1-4 similar to submucosal anesthesia
• Root canal/Pulp chamber
• Gain access to the pulp chamber or the to the canal root canal
• Needle insertion point
• Wedge the needle firmly injection is performed into the pulp
• Pulp chamber chamber or root canal
Volume of the injected solution • Deposit anesthetic injection. Relief usually solution under
• 0.3-05 ml pressure immediate
Step 11-13 similar to submucosal anesthesia

Intrapulpal injection Intraosseous injection Intraosseous injection (IO)

Advantages • The technique requires perforating the cortical bone by creating Indications
• It is required minimum dose of local anesthetic a small hole between the roots of the teeth with a specialized • pain control for dental treatment on a single or multiple teeth in a
rotary instrument. The dentist makes the perforation quadrant
• An alternative to partially successful regional nerve block approximately 5 millimeters apical to the buccal papilla. Applying
anesthesia constant pressure when the perforator is against the cortical Contraindications
• Rapid onset plate can lead to a build-up of heat. • Infection or severe inflammation at the injection site.
• Less traumatic than conventional block injections • Deposition of local anesthetic solution into the interproximal Deposit location
bone between two teeth
Disadvantages • Bone
• The administration of an injection of one-quarter to one-half of a
• The pain as the anesthetic is deposited cartridge of local anesthetic Needle insertion point
• May be difficult to enter certain canals • makes the perforation through the bone
• Need a small opening into the pulp chamber for optimum Volume of the injected solution
effectiveness • 0.5-0.7ml
Intraosseous injection (IO) Intraosseous injection (IO) Systems for intraosseus injection
• A needle or drill that makes the perforation through the bone and Advantages • Stabident System – 2 parts: a perforator, a solid needle that
delivers the local anesthetic • It is required minimum dose of local anesthetic perforates the cortical plate of bone with a conventional slow-
• A transfuser that acts as a conduit from the local anesthetic speed contra-angle handpiece, and an 8 mm long, 27-gauge
• An alternative to partially successful regional nerve block needle that is inserted into this predrilled hole for anesthetic
cartridge to the needle or drill anesthesia administration
• A latch tip or clutch that drive and governs the rotation of the • Rapid onset • X-tip – Composed of a drill and guide sleeve. The drill leads the
• needle or drill • Less traumatic than conventional block injections guide sleeve through the cortical plate, after which it is
• A motor or infusion drive that powers the rotation of the needle Disadvantages
separated and withdrawn. The guide sleeve remains in the bone
or drill and, while holding the local anesthetic cartridge in place, and accepts a 27-gauge ultrashort needle
powers the infusion plunger • The pain as the anesthetic is deposited • Intraflow – Combines the steps. The anesthetic cartridge is
• Adrenaline couldn`t be use in this method attached to a standard four-hole air hose and controlled by a
rheostat. The intraflow is a modified slow-speed handpiece that
consists of 4 main parts A needle or drill that makes the
perforation through the bone and delivers the local anesthetic. A
transfuser that acts as a conduit from the local anesthetic
cartridge to the needle or drill. A latch tip or clutch that drive and
governs the rotation of the needle or drill. A motor or infusion
drive that powers the rotation of the needle or drill and, while
holding the local anesthetic cartridge in place, powers the

Nerve blocks Nasopalatine or Incisive anesthesia Nasopalatine or Incisive anesthesia

1. Intraoral nerve blocks: Profound anaesthesia can be achieved by passing the needle
through the incisive papilla and injecting a small amount of
• Infraorbital nerve block solution
• Posterior superior alveolar nerve block This is a painful injection so it is better to give a few drops of
anesthesia superficially before proceeding with the rest of the
• Nasopalatine nerve block injection
• Greater palatine nerve block The aim is to anesthetize the nasopalatine nerve inside the
2. Extraoral nerve blocks: incisive canal
• Infraorbltal nerve block Area to be anesthetized: The mucosa of the Anterior part of the
palate opposite to the anterior teeth
• Nasopalatine nerve block Patient position • Head , neck and trunk on the same straight line•
• Anesthesia technique according to Egorov. The back of the chair is tilted so is in a supine right position• The
occlusal plan of maxillary teeth near to the operator’s shoulder
• Maxillary nerve block.
Dentist position The operator will sit from infront and to the that
the patient
Nasopalatine nerve block Nasopalatine or Incisive anesthesia Nasopalatine or Incisive anesthesia
Areas anesthetized • Technique
• None • Needle: – 25-27 gauge – short needle
Other Structures • 45°–90° to tissue at the edge of incisive papilla; watch for
• Anterior hard palate and overlying soft tissue of the maxillary blanching of the tissue; pressure anesthesia utilizing cotton tip
anterior teeth bilaterally (canine to canine) applicator.
Landmarks • Depth of Penetration
• Maxillary central incisors Incisive papilla • Short needle approximately 3–6 mm or until bone is lightly
contacted; 27 gauge
Penetration Site
• Anesthetic Solution
• Lateral to the incisive papilla
• 0.45 mL, or one fourth of a cartridge until blanching of tissue is
Deposit Location observed 20–30 seconds
• At incisive foramen

Infraorbital nerve block Infraorbital nerve block Infraorbital nerve block

• Areas anesthetized
• Teeth
• Technique
• Pulpal anesthesia of the maxillary central incisor, lateral incisor, canine, • Locate infraorbital foramen; Maintain pressure with finger over
premolars, mesiobuccal root of the first molar in 28% of population the foramen during injection; bevel toward bone; direct needle
• Other structures toward the foramen. Massage solution into foramen for 2 minute
• Periodontium of anesthetized teeth and facial soft tissue of maxillary arch, • Depth of Penetration
except for maxillary molar region; upper lip to midline; medial part of the
cheek; side of nose; lower eyelid
• Long or short needle, one half length of long needle and three-
fourths the length of short needle; 25 or 27 gauge
• Landmarks
• Anesthetic Solution
• Maxillary mucobuccal fold; infraorbital notch; infraorbital ridge; infraorbital
depression; infraorbital foramen; maxillary first premolar • 0.9–1.2 ml, or one half to two thirds of a cartridge
• Penetration Site • 60–90 seconds
• Height of mucobuccal fold superior to the maxillary first premolar
• Deposit Location
• Height of mucobuccal fold above the maxillary first premolar
Greater palatine (GP) block Greater palatine (GP) block Greater palatine (GP) block
• Areas anesthetized
• Technique
• Teeth
• Advance syringe from opposite side of mouth at right angle to
• None target area; use pressure anesthesia utilizing cotton tip
• Other structures applicator
• Lingual gingival tissue of maxillary premolars and molars and • Aspirate
posterior hard palate in one quadrant • Depth of Penetration
• Landmarks • Short needle approximately 3–6 mm or until palate is lightly
• Maxillary third molar contacted; 27 gauge
• Junction of maxillary alveolar process and posterior hard palate • Anesthetic Solution
• Greater palatine foramen • 0.45 mL, or one fourth of a cartridge until blanching of tissue is
observed 20–30 seconds
• Penetration Site
• Slightly anterior to the greater palatine foramen
• Deposit Location
• At greater palatine foramen

Posterior superior alveolar block (tubular Posterior superior alveolar (PSA) block Posterior superior alveolar (PSA) block
anesthesia) Areas anesthetized
Teeth
The posterior superior alveolar (PSA) nerve block is a commonly • Pulpal anesthesia of the third, second, and first maxillary molars
used technique for achieving anesthesia for the maxillary molars. entirely in 72% of population, mesiobuccal root not anesthetized in
It is high risk of a hematoma 28% of population
LA is deposited high above the tuberosity after aspirating to avoid Other structures
the ptyerygoid plexus • Periodontium of anesthetized teeth and buccal soft tissue of maxillary
molar region
Landmarks
• Maxillary mucobuccal fold; maxillary second molar; maxillary
tuberosity; maxillary occlusal plane; midsagittal plane
Penetration site
• Height of mucobuccal fold superior to the apex of the maxillary second
molar
Deposit Location
• Superior to apex of maxillary second molar and posterior and superior
to posterior border of maxilla at posterior superior alveolar foramina
Posterior superior alveolar (PSA) block Posterior superior alveolar (PSA) block Posterior superior alveolar nerve block
• Technique Other names - Tuberosity block
tubular anesthesia
• Upward 45° to occlusal plane, inward and backward 45° to Nerves anesthetized - Posterior superior alveolar nerve
midsagittal plane;
• Aspirate Indications
• Depth of Penetration Need to anesthetized two or more maxillary molar
Contra indications
• Short needle three-fourths of needle length; 25 or 27 gauge
Hemorrhage is high
• Anesthetic Solution
• 0.9–1.7 (1.8) mL, or half to a full cartridge 60–120 seconds Advantages
Atraumatic
Highly successful

Disadvantages
Risk of hematoma
No bony land mark

Extraoral Infraorbital Nerve Block Extraoral Infraorbital Nerve Block Extraoral Infraorbital Nerve Block
This procedure should be carried out under aseptic conditions.
• Nerves anesthetized This implies that the dentist should complete a surgical scrub, use
1. Infraorbital nerve sterile gloves, and surgically prepare the field.
2. Inferior palpebral , Lateral nasal & Superior labial nerves Using the available landmarks, the dentist should locate and mark
3.Anterior and Middle superior alveolar the position of the infraorbital foramen. The skin and
subcutaneous tissues should be anesthetized by local infiltration.
• Anatomical Landmarks a. Pupil of the eye b. Infraorbital ridge 1 1/2 – inch, 25 gauge needle attached to an aspirating syringe is
c. Infraorbital notch d. Infraorbital depression inserted through the marked and anesthetized area. Directing the
needle slightly upward and laterally facilitates its near the
entrance of the foramen, which opens downward and medially.
After careful aspiration, 1 ml of anesthetic solution is slowly
injected.
Extraoral Infraorbital Nerve Block Greater Palatine Nerve Block
• The greater palatine nerve innervates the palatal tissues and
bone distal of the canine on the side anesthetized.
• Use a 27 gauge short needle with the bevel toward the palate.
• Palpate the palate until the depression of the foramen is felt
(usually somewhere medial to the second molar)/
• Dry the tissue, and apply antiseptic and topical anesthetic for 2
minutes. Apply pressure with the swab for 30 seconds.

Greater Palatine Nerve Block Anesthesia technique according to Egorov Extraoral Maxillary Nerve Block
(for upper jaw) Nerves Anesthetized
• Continue pressure with the swab until the injection is completed.
• Place the bevel against the tissue and apply pressure enough to • According to the Egorov technique, the needle entry point is located 1 cm • Maxillary nerve and all its subdivisions peripheral to the site of
slightly bow the needle.
in front of the articular tubercle under the cheekbone. The needle injection
advances to the temporal bone.
• Inject a few drops of anesthetic. Areas Anesthetized
• This distance is fixed by a special stopper. Further, it enters at an angle of
• Release the pressure of the needle and advance the tip of the 90 degrees to the skin at a marked depth. 1. Anterior temporal and zygomatic regions
needle into the tissue slightly. Continue with this procedure of 2. Lower eyelid and side of the nose
applying pressure to the bevel and depositing a few drops of 3. Anterior cheek
anesthetic, then advancing, until the needle is in contact with the
palatal bone. 4. Upper lip and Maxillary teeth
• Deposit less than a fourth to a third of a cartridge of anesthetic 5. Maxillary alveolar bone and overlying structures
after negative aspiration is proven 6. Hard and soft palate, tonsil, and part of the pharynx
7. Nasal septum and floor of the nose
• Anatomical Landmarks : Midpoint of the zygomatic arch ,
zygomatic arch, coronoid process of the ramus of the mandible
located by opening and closing the lower jaw, lateral pterygoid
plate
Extraoral Maxillary Nerve Block Greater palatine foramen approach Extraoral approach
• Techniques This procedure should also be carried out under This is similar to that described above for the extra- oral approach
aseptic conditions. This implies that the dentist should complete This technique involves inserting a needle into the pterygopalatine to the foramen ovale. This time the target is the foramen
a surgical scrub, use sterile gloves, and surgically prepare the fossa via the greater palatine foramen. The patient has the mouth rotundum. The point of insertion is identical to that described for
field. open wide and the greater palatine foramen is identified as a the extraoral mandibular nerve block. Similarly, the needle is
depression medial to the distal surface of the second maxillary advanced until the lateral pterygoid plate is contacted. The depth
• The midpoint of the zygomatic process is located and the molar tooth. The needle is inserted into the greater palatine
depression in its inferior surface is marked. With a 25-gauge of insertion is noted. The needle is withdrawn and redirected
foramen and advanced at an angle of 45o superiorly and towards the pterygopalatine fossa. This is achieved by pointing
hypodermic needle, a skin wheal is raised just below this mark posteriorly to a depth of 30mm. At this point 2.0 ml of solution is
in the depression, which the dentist identifies by having the the needle 10o more superiorly and 15o more anteriorly until the
deposited. depth of insertion determined by the original needle insertion is
patient open and close the jaw.
reached. This is the point of delivery of solution.
• Using a 4-inch (8.8 cm), 22-gauge needle attached to a Luer-
Lok type of syringe, one measures 4.5 cm and marks with a
rubber marker. The needle is inserted through the skin wheal,
perpendicular to the median sagittal plane (skin surface) until
the needle point gently contacts the lateral pterygoid plate. The
needle should never be inserted beyond the depth of the
marker. The needle is withdrawn, with only the point left in the
tissue, and redirected in a slight forward and upward direction.
After careful aspiration 2 or 3 ml of a suitable anesthetic solution